Basic Information
| Provider Information | |||||||||
| NPI: | 1396796009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492012218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177876440 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4665 DOUGLAS CIR NW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447183673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304995700 | ||||||||
| FaxNumber: | 3304984229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 08/27/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35052008 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000000135910 | 01 | ANTHEM | OTHER | 050016704 | 01 | MEDICARE RAILROAD | OTHER | 0590623 | 05 | OH | MEDICAID |